SNF

Focused Care at Webster

CCN: 675848 · Webster, TX 77598 · Harris County

⚠ Abuse citation flag

Overview

Address
17231 Mill Forest, Webster, TX 77598
Phone
2814885224
Certified beds
120
Avg daily residents
74 (62% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare and Medicaid
Medicare/Medicaid since
2000-10-31
Setting
Urban
1 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
★★★★★ 2/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 3/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 5/5
Short-Stay Quality Measures ★★★★★ 1/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 3.63 3.85 3.64 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 0.44 0.67 0.44 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 0.77 0.85 0.77 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 2.42 2.32 2.43 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.21 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.06 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
3.16
hrs / resident / day
RN (weekend)
0.35
hrs / resident / day
Total nurse (adjusted, weekend)
3.17
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
67.7%
annual
RN turnover
60.0%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.36
higher acuity than avg
Case-Mix Index Ratio
0.99
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-01-30 10 6 5 198 1 198
Cycle 2/3 (prior) 2023-12-09 10 4 6 83 1 83
Total weighted health score
169.3
lower is better

Deficiencies (28)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

25 D/E/F Actual harm — potential for minor
1 G/H/I Actual harm
2 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. E 2025-11-18 2025-12-20
0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. E 2025-11-18 2025-12-20
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. J 2025-10-08 2025-10-31
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2025-10-08 2025-10-31
0576 Ensure residents have reasonable access to and privacy in their use of communication methods. D 2025-01-30 2025-01-31
0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. E 2025-01-30 2025-01-31
0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. D 2025-01-30 2025-01-31
0790 Provide routine and 24-hour emergency dental care for each resident. E 2025-01-30 2025-01-31
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2025-01-30 2025-01-31
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2025-01-30 2025-01-31
0602 Protect each resident from the wrongful use of the resident's belongings or money. D 2025-01-30 2024-12-31
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D 2024-11-21 2025-01-06
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D 2024-10-25 2024-11-25
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2024-10-25 2024-11-25
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2024-10-25 2024-11-25
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. H 2024-02-01 2024-02-21
0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. D 2023-12-09 2024-01-08
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E 2023-12-09 2024-01-08
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. E 2023-12-09 2024-01-08
0880 Provide and implement an infection prevention and control program. E 2023-12-09 2024-01-08
0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. D 2022-09-23 2022-10-14
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2022-09-23 2022-10-14
0610 Respond appropriately to all alleged violations. D 2022-09-23 2022-10-14
0637 Assess the resident when there is a significant change in condition D 2022-09-23 2022-10-14
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2022-09-23 2022-10-14
0759 Ensure medication error rates are not 5 percent or greater. E 2022-09-23 2022-10-14
0814 Dispose of garbage and refuse properly. D 2022-09-23 2022-10-14
0880 Provide and implement an infection prevention and control program. E 2022-09-23 2022-10-14

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 3.1% Medicaid 78.4% Other 18.5%

Operating performance

Operating Margin
-10.4%
Total Margin
-2.3%
Occupancy Rate
67.6%
Cost per Resident Day
$28

Revenue & costs

Net Patient Revenue
$6.6M
Total Costs
$819K
Net Income
-$163K

Balance sheet

Total Assets
$5.9M
Total Liabilities
$6.0M
Fund Balance
-$69K
Current Ratio
1.15

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: FOCUSED POST ACUTE CARE PARTNERS

Chain ID
224
Facilities in chain
25
Legal business name
FPACP WEBSTER LLC
Chain-average star ratings (for peer context)
Overall
2.2
Health
2.1
Staffing
1.6
QM
4.2

Owner / manager organizations (5)

Organization Role Association
FOCUSED POST ACUTE CARE PARTNERS LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 03/07/2019
FPACP WEBSTER LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 05/20/2019
FOCUSED POST ACUTE CARE PARTNERS LLC OPERATIONAL/MANAGERIAL CONTROL since 05/20/2019
FOCUSED POST ACUTE CARE PARTNERS MANAGEMENT, LLC OPERATIONAL/MANAGERIAL CONTROL since 05/20/2019
FPACP WEBSTER LLC OPERATIONAL/MANAGERIAL CONTROL since 05/20/2019

Owner / manager individuals (13)

Name Role Association
CONLEY, SHAWN 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 05/20/2019
MCKENZIE, MARK 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 03/07/2019
STRUBBE, LORETTA 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 05/20/2019
BROSSETTE, KEITH OPERATIONAL/MANAGERIAL CONTROL since 08/27/2024
CONLEY, SHAWN OPERATIONAL/MANAGERIAL CONTROL since 05/20/2019
FOSTER, STACY OPERATIONAL/MANAGERIAL CONTROL since 05/20/2019
HOYA, SHERRI OPERATIONAL/MANAGERIAL CONTROL since 10/01/2020
LOCKHART, CHRISTOPHER OPERATIONAL/MANAGERIAL CONTROL since 10/01/2020
MCKENZIE, MARK OPERATIONAL/MANAGERIAL CONTROL since 05/20/2019
STRUBBE, LORETTA OPERATIONAL/MANAGERIAL CONTROL since 05/20/2019
CONLEY, SHAWN CORPORATE OFFICER since 05/20/2019
MCKENZIE, MARK CORPORATE OFFICER since 05/20/2019
STRUBBE, LORETTA CORPORATE OFFICER since 05/20/2019

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Both
Sprinkler systems
Yes
Abuse citation flag
Yes — last 2 cycles
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $28 metrics.cost_per_resident_day
Cost Report Current Ratio 1.15 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 78.4% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 3.1% metrics.medicare_day_share
Cost Report Net Income ($) $-162,753 metrics.net_income
Cost Report Net Patient Revenue ($) $6,574,109 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 67.6% metrics.occupancy_rate
Cost Report Operating Margin (%) -10.4% metrics.operating_margin
Cost Report Total Assets ($) $5,913,966 metrics.total_assets
Cost Report Total Costs ($) $818,538 metrics.total_costs
Cost Report Total Fund Balances ($) $-68,640 metrics.fund_balance
Cost Report Total Liabilities ($) $5,982,606 metrics.total_liabilities
Cost Report Total Margin (%) -2.3% metrics.total_margin
Provider Information Abuse Icon Y Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.77319 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 2.42588 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.44225 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.64131 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.16858 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 74.2 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.85489 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.32340 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.67384 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.85213 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.39524 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.1 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.2 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 4.2 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 1.6 Chain Average Staffing Rating
Provider Information Chain ID 224 Chain ID
Provider Information Chain Name FOCUSED POST ACUTE CARE PARTNERS Chain Name
Provider Information City/Town Webster City/Town
Provider Information CMS Certification Number (CCN) 675848 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Harris County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2000-10-31 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 29.545 Latitude
Provider Information Legal Business Name FPACP WEBSTER LLC Legal Business Name
Provider Information Location 17231 Mill Forest,Webster,TX,77598 Location
Provider Information Long-Stay QM Rating 5 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -95.123 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 120 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 25 Number of Facilities in Chain
Provider Information Number of Fines 0 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.36464 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.99055 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 17231 Mill Forest Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name Focused Care at Webster Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 610 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 3 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 198 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 5 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 6 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-01-30 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 198 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 10 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 4 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-12-09 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 83 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 6 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 83 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 10 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.35346 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 60.0 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote — Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.21267 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.77143 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.42035 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.05871 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.44124 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.63301 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 1 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 2 Staffing Rating
Provider Information Staffing Rating Footnote — Staffing Rating Footnote
Provider Information State TX State
Provider Information Telephone Number 2814885224 Telephone Number
Provider Information Total Amount of Fines in Dollars 0.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 3.16136 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 0 Total Number of Penalties
Provider Information Total nursing staff turnover 67.7 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 169.250 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Both With a Resident and Family Council
Provider Information ZIP Code 77598 ZIP Code